Search

Introduction: Most tumour-related pathological fractures occur in patients with bone metastases. However, in mostly younger patients, a pathological fracture can be due to both a benign or a malignant bone tumour. Making the correct diagnosis from among these two differential diagnoses is enormously important. If the tumour is malignant, treating the fracture inevitably leads to tumour cell contamination and can significantly worsen the oncological situation. The aim of this review article is firstly to provide the reader with diagnostic assistance in the case of suspected pathological fractures, and secondly to focus on the treatment of pathological fractures occurring with benign bone tumours., Methods: This is a non-systematic review of the diagnosis and treatment of pathological fractures in benign bone tumours or tumour-like lesions, based on an electronic PubMed database search. We also present our own procedures, in particular for ruling out a malignant bone tumour., Results and Discussion: Whenever a fracture occurs in the absence of sufficient traumatic force, the possibility of a pathological fracture should always be considered. As well as taking a general history for a possible primary tumour, it is particularly important to ask the patient whether they had any pain before the fracture occurred. If the findings from clinical examination or conventional radiological imaging give rise to suspicion of a pathological fracture, an MRI of the affected skeletal section with contrast medium should be carried out before commencing any fracture treatment. A CT scan is also helpful for accurately assessing bone destruction. If a malignant or locally aggressive benign bone tumour such as giant cell tumour (GCT) or aneurysmal bone cyst (ABC) cannot be definitively ruled out through imaging, a biopsy is essential. The bone biopsy must always be carried out on the assumption that the histological work-up will reveal a malignant bone tumour; it must therefore be performed according to strict oncological criteria. If the radiological diagnosis is unambiguous, e. g., a juvenile bone cyst (JBC) or a non-ossifying fibroma (NOF), conservative treatment of the fracture can be considered, depending on the location. In the presence of a locally aggressive benign bone tumour such as a GCT or ABC, curettage of the tumour must be carried out as well as treating the fracture. With GCT in particular, neoadjuvant therapy with denosumab prior to curettage and osteosynthesis or en bloc resection of the tumour should be considered, depending on the extent of the tumour., Conclusion: Pathological fractures, especially in younger patients, should not be overlooked. Only after a malignant or benign locally aggressive bone tumour has been definitively ruled out should fracture treatment be performed. In the presence of a locally aggressive bone tumour, as well as treating the fracture, it is usually necessary to perform curettage of the tumour - also en bloc resection, where applicable, in the case of a GCT. Depending on the location, benign, non-aggressive tumours can be treated conservatively if necessary., Competing Interests: J. Hardes und A. Streitbürger weisen auf folgende Beziehung hin: Forschungsunterstützung durch die Firma Implantcast, Buxtehude. D. Spodeck, W.Guder,M.Nottrott, L.Podleska,und M.Dudda geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Introduction: Due to substantial advances in all medical disciplines, interdisciplinary cooperation is of major relevance in modern medicine. Given the rarity of benign and malignant bone tumours, diagnosis and therapy of these lesions is especially challenging. Focusing on typical cases, it is the aim of this article to illustrate the necessity of interdisciplinary cooperation., Methods: The scope of this article is to highlight the particular significance of interdisciplinarity in the diagnosis of bone tumours. To this end, we illustrate the interdisciplinary approach in typical clinical cases., Results and Discussion: The article demonstrates that a combined clinico-radiological approach is essential in the diagnosis of leave-me-alone lesions, and it underlines the essential role of an interdisciplinary correlation of clinical context, radiology and pathology in the interpretation of bone tumour biopsies. It documents the experience that all clinical aspects and diagnostic findings need to be synoptically integrated in a joint interdisciplinary tumour board to eventually find the correct diagnosis., Conclusion: It is generally accepted that the diagnosis of a bone tumour can often not be made by the pathologist alone but essentially requires interdisciplinary cooperation., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Megaendoprosthesis offer a viable treatment in complex revision arthroplasty cases with good functional outcome. In the context of a neoplastic indication, the diagnosis-related group (DRG) I95A is usually assigned with a relative weight of 4.906 (2021). In contrast, in revision arthroplasty, the appropriate DRG is assigned, depending on the joint replacement. The additional costs compared to the invoiced DRG are to be compensated by agreeing on hospital-specific individual fees. These complex revision arthroplasties set high technical and operative demands and are mainly performed in specialised departments. We conducted a cost-benefit analysis of the use of the megaendoprosthesis in revision cases in a specialised orthopaedic clinic, as a single centre study. The question we sought to answer was: Is cost recovery possible in the modified German DRG system (aG-DRG)?A retrospective single centre analysis of treatment costs was performed. From 2018 to 2020, 113 patients treated with a megaendoprosthesis reconstruction in a referral centre due to extensive bone loss after aseptic or septic revision of a hip or knee prosthesis were included in the study. Relevant case-related cost drivers of the aG-DRG matrix (including staff and material costs of the operating theatre area and the ward) were taken into account. The actual costs were determined according to the specifications of the calculation manual published by the German institute for the remuneration system in hospitals (InEK). For each case, the contribution margin was calculated by relating the hospital's internal costs to the corresponding cost pool of the aG-DRG matrix.According to the DRG system 2021, 17 different DRGs were used for billing - in 70% based on a patient clinical complexity level (PCCL) ≥ 4. Compared with the InEK calculation, there is a deficit of -2,901 € per case in the examined parameters. The costs of physicians show a shortfall in both the operating theatre and on the ward. Implant costs, which were supposed to be compensated by hospital-specific additional charges, show a hospital-specific shortage of -2,181 €. When analysing the risk factors for cost recovery, only these showed a significant difference.Implantation of the megaendoprosthesis in revision arthroplasty is often the last option to preserve limb function. At present, despite a high degree of specialisation and process optimisation, this treatment cannot be provided cost-effectively even in tertiary care. The politically desired specialised department structure requires sufficient reimbursement for complex cases. The economic outcome of each treatment case is often unpredictable, however the surgeon is confronted with these cases and is expected to treat them. The high standard deviation indicates large differences in the cost/revenue situation of each individual case. Our results show for the first time a realistic cost analysis for megaprosthesis in revision arthroplasty and underline the importance of an adequate hospital-specific charge, individually agreed by the funding units. The calculation should include not only the implant costs, but also the increased staff costs (increased, complex planning effort, quality management, surgery time, etc.)., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

As survival rates associated with the multimodal treatment of malignant bone cancer (osteosarcoma and Ewing's sarcoma) are satisfactory, health-related quality of life and the return to activity and sports by the affected patients have attracted increasing attention in recent years. Nowadays, limbs can be salvaged for most patients using modular endoprostheses. Such patients are typically adolescents and young adults who have high activity levels and thereby high demands for multimodal cancer treatment. This study aimed to evaluate the activity levels and sporting proficiencies that can be attained after modular endoprosthetic treatment of bone sarcomas as well as the extent to which physiotherapeutic and sports interventions influence functional outcome and activity levels.This non-systematic review of the literature focused on the return to activity and sports after modular endoprosthetic treatment of lower extremities bone sarcomas in adolescents and young adults. The electronic database PubMed was screened for relevant publications on this issue. A treatment algorithm for return to activity and sports in tumor orthopaedics is proposed.The objective activity level (gait cycles per day and gait intensities) in patients treated for bone sarcomas is reduced in short- and long-term follow-ups compared with healthy controls and patients with other cancers (leukaemia). Although a negative impact is observed in terms of motor performance, it shows improvement over time. Functional assessment at 12 postoperative months is sensible as neoadjuvant chemotherapy is completed by then. In long-term follow-up, patients with bone sarcomas can achieve high sports activity levels, i.e., type of sport, frequency/week and UCLA score, after modular endoprosthetic reconstruction. The maximum level is attained at 5 years postoperatively. Nevertheless, there is a shift from high- and intermediate- to low-impact sports. Only 20% of the patients participate in school sports regularly without limitations. The localisation of bone sarcoma, but not the rate of postoperative complications, influences the postoperative activity level. Individualised sports-related interventions during and after multimodal treatment can improve the short-term activity levels; moreover, "serious games" can improve motor performance and postural control. There is no evidence that intense activity levels leads to early loosening of the endoprosthesis. There is insufficient valid data on activity and sports after modular endoprosthetic treatment of bone sarcomas of the upper extremities.High preoperative activity levels of young patients with bone sarcomas must be considered in tumour orthopaedics. Limitations on sports activities have a significant negative impact on the quality of life and mental health of such patients. Therefore, tumour orthopaedic treatment has to focus on preserving an improvement in these factors. The overall existing evidence concerning this issue is weak. Additional studies to evaluate the ability to return to specific sports activities are desirable, as well as prospective interventional studies., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Bone sarcomas are extremely rare representing approximately 0.2% among all cancer types. Due to the rarity of these tumors both the patients and the physicians can overlook or misinterpret the first often unspecific symptoms of these tumors (pain, limping and swelling). Therefore, radiographic examination (X-ray and/or MRI) of the involved region in case of inexplicable symptoms is strongly recommended. The most common primary malignant bone tumor entity is osteosarcoma, followed by chondrosarcoma and Ewing sarcoma. Osteosarcomas and Ewing sarcomas occur predominantly in children, adolescents and young adults, while chondrosarcomas primarily affect older patients. Most of the tumors are located in the extremities and the pelvis and in about 90% of cases the surgical treatment can be performed by means of a limb-sparing wide resection. An endoprosthetic or biological reconstruction of the resulting defect, depending on several patient- und tumor-related factors, usually is necessary. Apart from the surgical treatment, patients with osteosarcoma and Ewing sarcoma require a pre- and postoperative chemotherapy, while Ewing sarcoma patients often undergo radiation therapy as well - in some cases as the only local therapy option. Regular follow-up examinations are required after the completion of treatment for the early detection and management of local and/or systemic recurrences. Diagnosis and therapy of these rare tumors must be obtained by an interdisciplinary approach for optimal patient care (i.e. oncologist, radiologists, pathologists, orthopaedic surgeons, radiotherapists). Without an interdisciplinary proceeding the risk of mistakes increases significantly, which can have grave consequences on the patients' prognosis and functional outcome. Therefore, the centralized treatment of these patients in specialized sarcoma centres is recommended., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: External quality assurance for revisions of total knee arthroplasty (TKA) and total hip arthroplasty (THA) are carried out through the AQUA institute in Germany. Data are collected by the providers and are analyzed based on predefined quality indicators from the hospital stay in which the revision was performed. The present study explores the possibility to add routine data analysis to the existing external quality assurance (EQS). Differences between methods are displayed. The study aims to quantify the benefit of an additional analysis that allows patients to be followed up beyond the hospitalization itself., Material and Methods: All persons insured in an AOK sickness fund formed the population for analysis. Revisions were identified using the same algorithm as the existing external quality assurance. Adverse events were defined according to the AQUA indicators for the years 2008 to 2011.The hospital stay in which the revision took place and a follow-up of 30 days were included. For re-operation and dislocation we also defined a 365 days interval for additional follow-up. The results were compared to the external quality control reports., Results: Almost all indicators showed higher events in claims data analysis than in external quality control. Major differences are seen for dislocation (EQS SD: 1.87 vs. claims data [cd] SD: 2.06 %, cd+30 d: 2.91 %, cd+365 d: 7.27 %) and reoperation (hip revision: EQS SD: 5.88 % vs. claims data SD: 8.79 % cd+30 d: 9.82 %, cd+365 d: 15.0 %/knee revision: EQS SD: 3.21 % vs. claims data SD: 4.07 %, cd+30 d: 4.6 %, cd+365 d: 15.43 %). Claims data could show additional adverse events for all indicators after the initial hospital stay, rising to 77 % of all events., Conclusions: The number of adverse events differs between the existing external quality control and our claims data analysis. Claims data give the opportunity to complement existing methods of quality control though a longer follow-up, when many complications become evident., (Georg Thieme Verlag KG Stuttgart · New York.)

Aim: Today, megaendoprostheses--which were originally designed for osseous defect reconstructions in tumour surgery--are being more frequently used for extensive bone defects in revision arthroplasty. The purpose of this study was to assess the complication rate and the functional results associated with megaendoprosthesis reconstruction of the proximal femur in a non-oncological patient group., Method: 28 patients (average age 72; SD 10 years) with a proximal femur replacement were retrospectively (mean follow-up 43 months) evaluated regarding the complication rate. The Harris hip score was used to assess the outcome. The revision surgery was indicated because of large bone defects caused by implant-associated infection (n = 16), periprosthetic fracture (n = 8) or aseptic loosening (n = 4)., Results: Overall 8 patients (28.6 %) had to undergo 1 (n = 5) or more (2 n = 2, 4 n = 1) revision surgeries because of dislocation (n = 4), aseptic loosening of the stem (n = 2) and periprosthetic infection (n = 2). A significant pain relief could be achieved from on average 9.0 to 38.7 (according to the Harris hip score). All patients could be mobilised postoperatively, but walking aids were necessary for the majority of patients., Conclusion: A proximal femur replacement in revision arthroplasty should be regarded as a salvage procedure for restoration of extremity function. With this procedure it is possible to achieve a--limited--walking ability for patients who were immobilised preoperatively in most cases. Furthermore, pain relief can be achieved. However, the--mostly multimorbid--patients must be informed preoperatively about restrictions in daily life in order to avoid exorbitant expectations., (Georg Thieme Verlag KG Stuttgart , New York.)

Aim: Different studies in the past have reported about the treatment of osteomyelitis. None of these analysed the long-term results and complications after surgical treatment of acute and chronic osteomyelitis. The aim of this study was to analyse the recurrence rate and sequelae of osteomyelitis patients., Patients and Methods: We analysed 53 children who were treated surgically between 1992 and 2004 for acute (n = 13) and chronic (n = 40) osteomyelitis. The histopathology was used for differentiation. With an average follow-up of 7.1 years (2 - 12.5 years) we examined the recurrence rate and the medical condition., Results: A causative organism was identified in 53.9 % of the children with acute (AOM) and in 17.5 % of the children with chronic osteomyelitis (COM). In most cases Staphylococcus aureus could be isolated. Local antibiotics were applied intraoperatively to 92.3 % of the children with AOM and to 90 % of the children with COM. Additionally, the children with AOM were treated for 56.7 days (14 - 104 days) and the children with COM for 49.1 days (6 - 130 days) with parenteral/oral antibiotics. 2 (15.4 %) children with AOM and 6 (15 %) children with COM had a recurrence. At the time of the last examination all children were free of recurrence. One of the patients with AOM had a painless motion deficit of the shoulder. 5 children with COM complained of either pain and reduced range of motion of the affected extremity or minor deformities., Conclusion: Infantile osteomyelitis requires a selective diagnostic approach and an immediate parental antibiosis. If the antibiotic treatment fails, abscesses or sequestra are formed, an operation is indicated. With an adequate multidisciplinary cooperation, recurrence and sequelae can be avoided.